Federal restrictions preventing Medicaid reimbursement for non-abortion services at Planned Parenthood have ended, restoring coverage for routine healthcare provided at these clinics. States now have discretion to determine whether Medicaid enrollees can access covered services at Planned Parenthood locations that remain operational. The change takes effect immediately, reversing a previous ban that prohibited Medicaid payment for any services delivered by Planned Parenthood providers, including primary care, family planning, STI testing, and cancer screenings. Medicaid managed care organizations must now determine network participation and reimbursement policies for these providers according to state guidance.
Why it mattersMCOs must update provider networks, claims systems, and member communications to reflect reinstated coverage of qualified services at Planned Parenthood clinics, subject to state-specific participation rules.
Managed Care · Maternal
The Congressional Budget Office's February 2026 projections show significant reductions in Medicaid enrollment and federal spending over the next decade following passage of the 2025 reconciliation law. The analysis compares current projections to pre-reconciliation baselines, quantifying the impact of policy changes including eligibility restrictions, state flexibility provisions, and federal funding modifications. CBO accounts for both legislative changes and updated economic assumptions in projecting enrollment trends and program costs through 2036. The projections provide the first comprehensive federal assessment of how reconciliation provisions will reshape Medicaid program size and federal financial participation.
Why it mattersThese projections establish the federal baseline for managed care organizations to model membership losses, revenue impacts, and state contract modifications as reconciliation provisions phase in.
Managed Care · Finance
The Government Accountability Office reports that federal Medicaid and Medicare spending for services provided in assisted living facilities totaled at least $12 billion in 2024, including $3.5 billion in federal Medicaid spending and $8.5 billion in Medicare spending. Forty-four states cover assisted living services through their Medicaid programs, with 29 states using home- and community-based services (HCBS) waivers as of March 2025. GAO notes the $12 billion figure is likely an undercount due to data limitations, as assisted living facilities are not uniformly defined or consistently identified in program data. Medicare generally does not cover assisted living services but covers other health care such as hospice in these settings.
Why it mattersThis GAO analysis quantifies federal spending in assisted living settings and confirms HCBS waivers remain the dominant coverage mechanism for 29 states, affecting MCO long-term services and supports benefit design and network requirements.
LTSS · Managed Care
The HHS Office of Inspector General reviewed Part D plan formularies for 2026 and found that plans generally include drugs commonly prescribed to dual-eligible beneficiaries. The analysis examined formulary coverage patterns for medications frequently used by individuals enrolled in both Medicare and Medicaid. The report provides insight into whether dual eligibles have adequate access to needed medications through Part D coverage. This matters for Medicaid managed care organizations that coordinate benefits for dually eligible members and must ensure continuity of pharmacy coverage across programs.
Why it mattersMCOs serving dual eligibles must coordinate Part D and Medicaid pharmacy benefits, and formulary adequacy directly affects care continuity, member grievances, and wraparound coverage obligations.
Pharmacy · Managed Care
The Drug Enforcement Administration announced plans to temporarily classify 7-hydroxymitragynine (7-OH) and three related synthetic kratom compounds as Schedule I controlled substances, placing them in the same regulatory category as heroin and LSD. The classification applies to synthetic versions of the psychoactive compound found in kratom products. If finalized, the scheduling action would prohibit manufacture, distribution, and possession of these substances, with enforcement implications for entities handling these compounds. The timing of implementation and comment period was not specified in the available content.
Why it mattersMedicaid MCOs covering behavioral health or substance use disorder treatment may need to update formularies, prior authorization protocols, and member communications if kratom-containing products are used by enrollees for pain or opioid withdrawal management.
Behavioral Health · Pharmacy